History of MHPAEA

Mental Health Parity is designed to ensure individuals receive equal access to Mental Health and Substance Use Disorder (MH/SUD) benefits as they do for Medical and Surgical (MED/SURG) benefits. This quest for parity began legislatively in 1996 with the Mental Health Parity Act (MHPA), prohibiting insurance companies from imposing more restrictive annual or lifetime dollar limits on mental health benefits than MED/SURG. Since then, many regulations have been passed to help achieve this goal.

Despite previous efforts and regulations, disparities between MH/SUD and MED/SURG benefits have continued to grow over the last 15 years. In 2022, according to the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Survey on Drug Use and Health (NSDUH), almost 54.6 million people aged 12 and older were diagnosed for needing treatment for substance abuse, and only 24% of that population were able to receive treatment.1 Additionally, a study by RTI International showed that in 2021, out-of-network behavioral health clinician office visits were reported to be 3.5 times higher than all MED/SURG out-of-network office visits.2  

Final Rules to the MHPAEA were released by the Departments of Labor, Health and Human Services, and the Treasury on September 9th, 2024, with the intent to rapidly address these barriers. These rules take effect on January 1, 2025, with some requirements having a delayed application until January 1, 2026. The Final Rules expand on previous requirements, provide clarification for group health plans and health insurance issuers to stay compliant with MHPAEA, and aim to eliminate any restrictions on MH/SUD treatments or resources, ensuring the same level of coverage as MED/SURG benefits. 

The final regulations are complex and will be cumbersome for all employers, especially those with self-insured plans.  At the core of the regulation are two requirements: a Benefit Coverage Requirement and an NQTL Comparative Analysis Requirement.

Benefit Coverage Requirement

This review must ensure that financial requirements and quantitative treatment limitations (QTL) are not more restrictive when comparing MH/SUD and MED/SURG benefits. The final rules remove away from the tests mentioned in 2013 and emphasized that plans cannot impose an NQTL that is more restrictive on MH/SUD benefits compared to MED/SURG benefits. To determine whether the NQTL meets the requirement to be no more restrictive, the plan must satisfy both a Design and Application Requirement as well as a Relative Data Evaluation Requirement. 

Design and Application Requirement: Plans must show that the processes, strategies, evidentiary standards, and other factors used when both designing and applying the NQTL are comparable, rather than the previously only evaluating the application itself. Additionally, a key provision prohibits using discriminatory factors or evidentiary standards when designing the NQTL.

When evaluating the plans, the regulation is clear that health plans must provide “meaningful benefits,” which entail covering at least one core treatment in each category for MH/SUD benefits, as they do for MED/SURG. The six recognized categories are emergency services, in-network inpatient, out-of-network inpatient, in-network outpatient, out-of-network outpatient, and prescription drugs. For example, if a health plan covers a hospital surgery in the inpatient category, it must also provide access to mental health treatment, such as inpatient psychiatric care, in the same category. If they provide antibiotics in the prescription drugs category, they must also provide antidepressants.

Data Evaluation Requirement: Plans must collect and evaluate data to assess the relevant outcomes of applying the NQTL. Plans and issuers must identify material differences in access to services and take reasonable action to address them. Although the Departments will not provide a set list of required data, they expect plans to collect data relevant to most NQTLs, allowing flexibility based on the NQTL in question. If data is lacking, plans must state why it is missing, how they will collect it in the future, or provide a reasoned justification concluding no data exists.

If the Departments determine that the NQTL is more restrictive and that the above requirements are not met, they can enforce plans to stop imposing the NQTL on their MH/SUD benefit offering.

NQTL Comparative Analysis Requirement

The Final Rules reiterate the need for an NQTL comparative analysis, which has been a requirement since the CAA (2021). The analysis requirements are robust, requiring the Plan to explain how and why the Benefit Coverage Requirements are satisfied within their NQTL Comparative Analysis.  This narrative must be detailed and include the following Content Elements:

This analysis must consider all facets of the plan, including core treatment, standards of care, utilization, access, networks, prior authorizations, etc. The plan must assess any material differences and what meaningful actions are being taken to ensure compliance. 

For ERISA-covered plans, the named plan fiduciary must verify an appropriate analysis was conducted with a prudent process.  Fiduciaries are also responsible for continually monitoring the plan and compliance with the NQTL analysis. 

The comparative analysis must be readily available upon request and provided within the specific timeframe: 10 business days for the relevant Secretary, and 30 days for participants or beneficiaries. If an insufficient analysis is determined, plans must submit additional information within 10 business days. If there is an initial determination of noncompliance, they have 45 calendar days to make corrections. If there is a final determination of noncompliance, the plan must inform all enrolled participants and beneficiaries within 7 days and provide the Secretary with a copy of this notice, along with the names of everyone involved in the process.

Action Plan

The Departments recognize that employers with self-insured health plans rely on TPAs and service providers for plan administration and understand the challenges in obtaining the necessary comparative analyses or required data. However, plans and issuers are ultimately responsible for compliance with MHPAEA. If you don’t already have a comparative analysis on hand, it should become a top priority due to the quick turnaround response times outlined. It is recommended to consult with a legal partner for an in-depth analysis. Additionally, the MHPAEA Final Self-Compliance Tool, finalized in 2020, serves as a valuable resource, guiding plans and issuers to meet compliance with MHPAEA’S parity requirements. This tool has not been updated, but that is expected. 

The Final Rules generally apply starting January 1, 2025, though provisions like meaningful benefits and certain comparative analysis requirements are delayed until January 1, 2026, to give employers more time to comply.

Although we recommend that employers carefully examine their plans and work toward immediate compliance, a lawsuit has been filed and more are anticipated.  The lawsuit from ERIC (The ERISA Industry Committee) indicates that the new regulations are fundamentally flawed, exceed the statutory authority that Congress provided to the agencies and threaten the ability to offer quality and affordable benefits in compliance with applicable laws. 

1 SAMHSA (2023), Key substance use and mental health indicators in the United States: Results from the 2022 National Survey on Drug Use and Health (HHS Publication No. PEP23-07-01-006, NSDUH Series H-58), https://www.samhsa.gov/​data/​report/​2022-nsduh-annual-national-report.
2 Mark, T.L., Parish, W. (2024), Behavioral health parity—Pervasive disparities in access to in-network care continue, RTI International, https://dpjh8al9zd3a4.cloudfront.net/​publication/​behavioral-health-parity-pervasive-disparities-access-network-care-continue/​fulltext.pdf.

The past year has seen a surge in class action lawsuits against some of the largest employers in the country, alleging that fiduciaries are breaching their duties in deciding how to allocate forfeitures. While these claims are not necessarily valid, it may be prudent to take a moment during your next benefits committee meeting to review what your plan document requires, assess what your plan is currently doing, and determine whether any changes are necessary.

Before this recent litigation, the issue of forfeitures appeared to be well settled. Participants in a 401(k) or similar defined contribution plan are always fully vested in their own contributions. However, many plans impose a vesting period before participants become fully vested in employer contributions (such as matching contributions). If a participant leaves the company before completing the vesting period, the employer contributions are forfeited. According to the IRS, these forfeited amounts can be used by the plan sponsor to offset plan expenses or reduce employer contributions. Consequently, many plan documents allow both uses of forfeitures and leave the decision to plan fiduciaries.

In these class action lawsuits, plaintiffs allege that using forfeitures to reduce employer contributions, though permitted by the IRS under the Tax Code, violates ERISA’s fiduciary duties, which are administered by the Department of Labor (DOL). Plaintiffs argue that forfeitures are plan assets and, as such, may only be used to pay benefits or the reasonable expenses of the plan. They further contend that ERISA’s duty of loyalty requires fiduciaries to prioritize participants’ interests over those of the plan sponsor. Specifically, the lawsuits claim that using forfeitures to reduce employer contributions rather than to offset participant-borne plan expenses constitutes a fiduciary breach.

It is important to note that these cases are in their early stages, that the legal theories involved are novel, and that the DOL has never taken the position that using forfeitures to reduce employer contributions is a fiduciary breach. Nevertheless, given the current controversy, plan fiduciaries may benefit from reassessing their approach to forfeitures by addressing three key questions.

1. What does your current plan document provide?

Plan documents often take different approaches to forfeitures. Some mandate a single use, while others specify an order of priority for different uses or allow multiple uses at the fiduciaries’ discretion. Fiduciaries should be familiar with the requirements of their specific plan document.

2. What is your plan actually doing?

Fiduciaries are obligated to follow the terms of the plan document. For example, if the document requires forfeitures to be used to offset plan expenses, using them to reduce employer contributions would constitute a breach of duty, and vice versa. Unlike the recent lawsuits, the duty to adhere to plan terms is a well-established legal principle that the DOL has enforced in the past. Fiduciaries should ensure their practices align with their plan document and consult legal counsel if any discrepancies are identified.

3. Does your current plan language reflect your intentions?

In light of recent litigation, it is worth considering whether the current plan language aligns with your goals. Do you want fiduciaries to have discretion, or should the plan document provide clear direction? For instance, if the plan document specifies that forfeitures will be used to reduce employer contributions, fiduciaries must follow that directive unless it is determined to be unlawful. Clear guidance in the plan document may shift the decision from a fiduciary responsibility to a “settlor” decision by the plan sponsor, reducing fiduciary discretion and potential liability.

There are several approaches to handling forfeitures, and fiduciaries should consult with legal counsel to evaluate the specifics of their plan and circumstances. However, taking the time to review your plan’s current practices is a straightforward and valuable step and a sensible addition to your 2025 fiduciary checklist.

In today’s rapidly evolving workforce, one-size-fits-all benefits are no longer sufficient to meet the diverse needs of employees. As expectations shift toward personalized and flexible offerings, voluntary benefits are emerging as a vital solution. These supplemental programs empower employees to customize their benefit packages by adding coverage tailored to their unique personal, health, and financial circumstances.

For employers, voluntary benefits offer significant advantages, including enhanced employee engagement, improved retention rates, and a more comprehensive approach to wellness. Additionally, since employees often bear the cost of these programs, they present a low-risk, cost-effective investment that boosts satisfaction and productivity.

What Are Voluntary Benefits?

Voluntary benefits are optional, supplemental offerings provided by employers in addition to traditional health insurance and retirement plans. These benefits are typically employee-paid, allowing individuals to select the coverage that best meets their needs.

Common examples of voluntary and supplemental benefits include:

This graph breaks down the most common insurance benefits offered according to Alera Group’s 2024 Employee Benefits Survey:

Meeting Employee Needs: The Rise of Voluntary Benefits

As the workforce becomes more diverse, employees are seeking benefits that go beyond traditional offerings. Over 75% of employers offer Medical, Dental, Vision, Life, and AD&D, with the number and type of benefits varying by employer size. Larger employers tend to offer a greater variety of benefits and are more likely to offer supplemental products, such as pet insurance. Employees want to feel valued, and a broad range of benefits demonstrate an employer’s commitment to their well-being, while also allowing employees to select products that best fit their needs.

Voluntary benefits align with the growing demand for personalized, flexible workplace solutions. With more employees working remotely and managing diverse personal circumstances, the ability to choose supplemental benefits has become increasingly important.

The Value of Voluntary Benefits for Employers and Employees

For Employees:
For Employers:

How Can Employers Implement Voluntary Benefits?

To introduce voluntary benefits successfully, employers should follow these steps:

1. Understand Employee Needs

Use employee surveys or analyze workplace trends and healthcare data to identify areas where employees might benefit from additional support, such as health coverage, financial protection, or wellness initiatives.

2. Evaluate Vendors and Packages

Assess potential vendors and benefits packages based on factors like cost, employee participation rates, and ease of administration. Ensure employees have easy access to these benefits and understand their value.

3. Communicate and Educate

Clear communication and ongoing education are crucial. Employers should regularly inform employees about available options, provide updates, and encourage participation.

Voluntary benefits are becoming an essential tool for employers seeking to support their workforce in ways that go beyond traditional offerings. By offering flexibility and choice, voluntary benefits empower employees to address their personal health, financial, and well-being needs while helping employers enhance engagement, retention, and overall satisfaction.

As healthcare costs continue to rise, employers are exploring innovative strategies to manage expenses while maintaining quality coverage. One increasingly popular option is joining an insurance consortium or coalition—a group of organizations that collaborate to provide insurance coverage. For employers considering self-insuring medical costs, consortiums offer several compelling advantages:

Alternative Funding Opportunities

Coalitions enable organizations to explore cost-effective funding models, such as self-insurance or utilizing a captive. By pooling resources, members share costs and risks across a larger base, reducing financial volatility while creating potential savings.

Group Purchasing Power

Collaborating within a consortium enhances buying power. Members can secure volume discounts and negotiate better contract terms with key vendors, including medical third-party administrators (TPAs), pharmacy benefit managers (PBMs), stop-loss carriers, and more. Additionally, consortiums often extend group benefits to services like point solutions, data warehousing, and wellness programs, maximizing value for all participants.

Claims Savings

Self-funding claims through a TPA allows employers to avoid high insurer premiums and directly manage healthcare costs. This approach can lead to significant savings, particularly when combined with a coalition’s shared resources.

Data

Consortium structures typically provide regular access to claims data, offering employers greater transparency and control. With actionable insights into trends and spending, organizations can make informed decisions and proactively address cost drivers throughout the year.

Engage with Like-Minded Organizations

While a variety of collaboratives exist, many are designed to bring together organizations of a similar nature, whether based on the type of organization, geography, size, or the nature of the business. These organizations not only pool risk but also collaborate, enabling members to exchange ideas, benchmark performance, establish common plan designs, and access shared administrative services. These collective efforts create a stronger foundation for sustainable healthcare strategies. One successful example is our client edRISK, which includes edHEALTH. We’ve worked with edHEALTH since the beginning and today it’s an 11-year-old member-owned group of educational institutions that are saving money on their employee health insurance costs and uncovering new opportunities to improve health and value for their faculty and staff.

Is a Collaborative Right for Your Organization?

While joining a consortium may seem like a significant step, the potential benefits often outweigh the effort required. From cost savings and risk mitigation to enhanced data transparency and collaboration, collaboratives are a powerful tool for employers seeking sustainable healthcare solutions. To learn more about how consortiums can benefit your organization, please reach out to us.

High interest rates have been an unwelcome storm for many parts of the economy, but defined benefit pension Plan Sponsors have rejoiced at the end of the long drought of historically low interest rates. The sharp rise in interest rates—and the accompanying reduction in plan funding liabilities—has led to a wave of plan terminations, annuitizations, and pension risk transfers. A key feature of this recent activity was the prioritization of innovative alternatives to traditional termination strategies, which fully protect plan participants while reducing annuitization and termination costs.    

Captive Reinsurance and Defined Benefit Plans

One innovative solution is to use a Plan Sponsor’s captive insurance company to reinsure the risks of the issuing insurer’s annuity contract. This contract funds the defined benefit plan while it remains active and provides annuities to participants if the plan is later terminated. By partnering with a fronting insurer, the captive assumes the primary underwriting risk, significantly reducing the cost of the annuity. Depending on the structure of the program, this arrangement may require the approval of the U.S. Department of Labor (DOL) through the grant of an individual prohibited transaction exemption. In July, the DOL tentatively authorized the first such arrangement and submitted it for public comment. Tentative authorization allows the Plan Sponsor to proceed with the transaction, after which final authorization would be issued.

The DOL proposed the individual exemption in response to an application from the Memorial Sloan Kettering Cancer Center (MSK). MSK sponsors a well-funded, frozen defined benefit pension plan with obligations of roughly $1.5 billion. This approach results in plan savings of approximately 10% compared to traditional plan annuitization.

Primary Benefits Test and Other Exemption Conditions

As with any individual exception, the DOL requires that a program meet certain conditions. The most significant is the “Primary Benefits Test,” which requires the majority of the economic benefit from the transaction to accrue to the plan participants and beneficiaries. In the MSK proposed exemption, just over half of the savings under the reinsurance arrangement will be directed to participants in the form of a one-time, universal benefit increase, resulting in a material increase of as much as 5% for participants in the frozen plan. This benefit increase would not be achievable using a traditional annuity solution.

The proposed exemption also requires ongoing oversight and approval by an independent fiduciary authorized to act on behalf of the plan, and regular reporting to DOL and state insurance regulators, both of whom will provide continuous oversight.

New Take on a Proven Process

While the use of a captive to reinsure third-party insurance company risk for ERISA-covered employee benefits is not new— the DOL has granted dozens of individual exemptions in connection with death, disability, and AD&D benefits in the past 25 years—this is the first time proposing such a tactic for a defined benefit pension plan annuity. 

An individual exemption is necessary because the third-party annuity issuer is engaged by the plan with the understanding that it will reinsure its risk with the Plan Sponsor’s wholly-owned captive insurer, an arrangement that involves fiduciaries approving party-in-interest transactions prohibited by ERISA Sec. 406(a) and 406(b). To propose the exemption, the DOL used its authority under ERISA Sec. 408(a) to grant administrative exemptions where the DOL finds doing so to be in the best interest of participants, protects their benefits, and is administratively feasible.

Captive reinsurance is an increasingly important part of the employee benefits landscape for large Plan Sponsors, offering better control of costs; more timely and accurate claims data; and more efficient plan administration.   

This is a welcome development for Plan Sponsors who have been looking for alternative avenues that allow them to provide more benefits to their plan participants while lowering the total cost of the transaction. This structure, widely used in European markets, could potentially create a new avenue for plan terminations in the U.S. market.

As we slowly approach the end of 2024, we had the pleasure of sponsoring and attending The Northeast HR Association (NEHRA)’s Annual Conference in the scenic Newport, RI. NEHRA brings together HR experts across the region to discuss current trends and developments impacting the HR and benefits industry. Some of the topics I found most noteworthy include:

Championing Diversity, Equity and Inclusion (DEI)

Championing DEI was a focal point at NEHRA’s Annual Conference this year, underscoring its significance in today’s workforce. By actively promoting diverse perspectives, organizations can enhance creativity and problem-solving capabilities, driving better business outcomes and creating equitable workplaces. Here are some related sessions I found impactful:

Fostering a Supportive (& Efficient) Work Culture

Creating a supportive yet efficient work culture remains a challenge for HR teams nationwide. Speakers shared best practices for prioritizing collaboration and open communication while emphasizing efficiency. This focus on supportive environments that boost employee morale and productivity was a hot-button topic this year.

– HR leaders explored unique “Situational Awareness & De-Escalation [tactics] in the Workplace” and tips for addressing high-tension workplace situations.

– As the war for talent continues, two talent acquisition professionals discussed the importance of “Strategic Flexibility: [and] Navigating Talent Shortages with Flexible Hiring Practices.”

-Berklee College of Music’s Associate Director of Talent Acquisition discussed the importance of “Stay Interviews” and how simple check-ins can remind employees of their importance to organizational success.

Supporting Mental Health

Mental health continues to be a top priority for  HR and benefits professionals across the region. Workshops and panels highlighted the need for initiatives that reduce stigma and promote work-life balance. By prioritizing mental health, HR professionals can create happier, healthier workplaces that enhance company culture and drive long-term growth. Below are some valuable sessions I’d like to spotlight.

– This year, attendees were able to enjoy a Sunrise Wellness Walk each morning of the conference. It provided a great opportunity to destress and explore the beautiful Newport neighborhood.

– As isolation and loneliness continue to impact many Americans, the session “Isolation, Inclusion and Workplace Collective Care: Strengthening Staff Mental Health” showcased tactics  for fostering a supportive environment.

– A clinical psychologist addressed “Getting Intentional About Managing Stress and Burnout: From Personal Practice to Organizational Impact,” providing guidance on navigating personal stress and building confidence.

In summary, the NEHRA’s Annual Conference created a vibrant atmosphere for networking and meaningful discussions on pressing trends shaping the HR landscape. We thoroughly enjoyed reconnecting with industry leaders, meeting emerging talent, and participating in insightful sessions. We look forward to seeing how these discussions evolve at next year’s conference.

Regardless of the specific line of coverage, claim audits are a best practice for employers and plan sponsors to ensure accuracy, identify errors, and document process gaps. A comprehensive claims audit can uncover issues related to compliance, adherence to contractual provisions, and consistency with best practices.

While most employers and plan sponsors understand the value of a claim audit, it is common to struggle with knowing where to start, and more specifically, when to start. For clients looking to audit their disability claims, we recommend considering the following factors in determining an optimal timeframe:

1. Vendor Implementation

If you are implementing your fully-insured disability plan with a new carrier or your self-funded disability plan or program with a new claim administrator, conducting a claim audit after the go live date can ensure that:

Conducting a claim audit post-vendor implementation can help solidify the foundation for the relationship and serve to identify opportunities for improvement before they grow into more significant roadblocks as the volume of claims increases.

2. Renewal & Stewardship

Whether you have a vendor administering your self-funded disability plan or program or a carrier insuring your fully-insured plan, it may make sense to conduct a claim audit in anticipation of your renewal, allowing you greater insight into:

As your team comes to the table to advocate for a fair renewal, audit findings can be a powerful negotiation tool. They can be used not only to position your organization for a more favorable renewal, but also as leverage to correct those findings that have had a negative impact on the plan or program’s financials and/or your employees’ experience.

3. Compliance

When determining the right time for a disability claim audit, if your plan is subject to The Employee Retirement Income Security Act (ERISA), your fiduciary duties may drive your decision to conduct an audit. As the plan sponsor, your organization is a fiduciary and must act prudently. An audit is one way to fulfill your fiduciary duty to act prudently as it not only monitors your vendor’s performance, but also ensures that the plan is in compliance with ERISA, the Internal Revenue Code, and other applicable laws.

4. Trend

Most employers receive some type of regular reporting and claims analysis from their vendor partners. When considering a claim audit, pay close attention to the data you are receiving, and consider setting things in motion if your plan or program’s experience is yielding an unexpected or new trend. In doing so, the claim audit can:

5. Self-Funded, Self-Administered

If you have a self-funded disability plan or program which you manage inhouse, you may want to consider establishing a routine cadence for conducting an audit of your team’s claim handling to:

Conclusion

Disability claim audits should be one tool in an employer’s toolbox for ensuring compliance, vendor and internal performance, and an overall positive claim experience for your employees. In conducting a claim audit, employers need to determine stakeholders involved, resources (internal or external), data gathering methods, goals, and processes. While the ideal time may vary by employer, the question of when to conduct the audit is another integral component of your claim audit strategy and should not be overlooked.

If you are interested in conducting a claims audit but need guidance or an objective partner to assist, please get in touch with the Spring team.

Spotlight on Cancer Point Solutions: Supporting Employees with Targeted Innovations

In today’s rapidly evolving healthcare landscape, cancer remains one of the most complex and challenging conditions to treat and is a top cost driver for many employers, including colleges and universities. Thankfully, advancements in cancer care are offering hope and transforming patient outcomes. One of the most promising developments is the rise of cancer point solutions, which aim to address the specific needs of cancer patients through targeted interventions and comprehensive care models.

What Are Cancer Point Solutions?

Cancer point solutions are specialized programs or services designed to address key aspects of cancer care, from prevention and diagnosis to treatment and survivorship. These solutions often combine cutting-edge technology, personalized care, and multi-disciplinary approaches to improve patient outcomes and enhance the overall healthcare experience.

Why Are They Important?

Traditional cancer treatment often involves navigating a fragmented system of specialists, treatments, and services. Cancer point solutions are designed to streamline these touchpoints by offering a holistic approach that integrates various aspects of care. These areas may include:

Benefits to Patients and Providers

Cancer point solutions offer several advantages to both patients and healthcare providers:

  1. Improved Patient Outcomes: By leveraging innovative treatments and technology, cancer point solutions can lead to more successful outcomes, fewer hospital readmissions, and improved quality of life for patients.
  2. Cost-Efficiency: Early detection, personalized treatments, and streamlined care processes can reduce unnecessary treatments and hospital visits, ultimately lowering overall healthcare costs.
  3. Enhanced Care Coordination: With all aspects of cancer care integrated under one solution, providers can collaborate more effectively, reducing the risk of miscommunication and errors in treatment and improving the patient experience.

How Cancer Point Solutions Are Shaping the Future

As healthcare systems continue to adopt value-based care models, cancer point solutions may play an increasingly important role in optimizing care delivery. By focusing on both clinical and holistic outcomes, these solutions not only enhance patient care but also align with broader goals of improving efficiency and contributes to a holistic employee benefit model to support employees at various points in their lives.

Conclusion

While many cancer patients may have access to certain benefits through their providers and care teams, providing additional support through an employee benefit solution can give employees seeking care or caregivers supporting their family members additional resources and tools during a difficult time. By embracing these innovative models within a benefits program, employers can help their employees access more personalized, coordinated, and effective care, ultimately improving the lives of those affected by cancer and positively impacting organizational population health.

For more information on how our health and welfare consulting team can help you implement or optimize cancer point solutions within your organization, please contact us today.

1 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8634312/
2 https://www.cancer.org/#:~:text=The%20American%20Cancer%20Society%20offers,patients%2C%20families%2C%20and%20caregivers
3 Improving Modern Cancer Care Through Information Technology
4 Patient-Centered Cancer Treatment Planning: Improving the Quality of Oncology Care. Summary of an Institute of Medicine Workshop

Workforce populations tend to be diverse in terms of demographics as well as other factors such as geography. This is one of the primary reasons healthcare programs are aligned with and sponsored by employers. These programs aim to achieve high enrollment to accommodate the demographic diversity among members. This, in turn, creates a system where the highest utilizers are subsidized by the leanest. There are several typical drivers that affect utilization: age, gender, morbidity, family size, etc. For mature populations participating in employer-sponsored healthcare programs, new hires with more favorable demographic characteristics help offset rising costs for aging employees, providing a consistent balance between those subsidizing and those being subsidized.

One of the largest demographic drivers of cost is age. As age increases, so do costs. When a population has aging members staying on well beyond 65, it becomes difficult to maintain the same influx of younger members to offset these rising costs. There are many industries where employees tend to work beyond age 65, such as education, public administration, and real estate. Additionally, due to rising retirement costs and increases in the cost of living, it has become necessary for many individuals to work beyond the traditional retirement age. The result is an average age that dramatically increases over time and average plan costs that outpace already burdensome medical and pharmacy trend rates.

How can we control these ongoing costs?

In general, there are many levers typically used to control healthcare costs. Many of them still make sense in the present environment, though they may be unattractive in a competitive employment situation. Examples include increased employee cost-sharing, leaner healthcare offerings, more stringent participation requirements, disease management, utilization management, and leaner pharmacy formularies.

How can we specifically address older members?

In the case of consistently increasing average age, these cost-control approaches may be temporary and insufficient. Further steps may include such approaches, but employers may also seek to decrease the number of older members remaining enrolled in the plan. Some specific suggestions include:

In summary, mitigating the increase in medical and pharmacy costs over time is already a significant challenge for employers, and aging populations can exacerbate these increases. It’s important for employers to address these issues head-on or face financial headwinds that could impact their stability. Please reach out to our team to explore these solutions further.

1 https://newsroom.fidelity.com/pressreleases/fidelity-investments–releases-2024-retiree-health-care-cost-estimate-as-americans-seek-clarity-arou/s/7322cc17-0b90-46c4-ba49-38d6e91c3961#_edn2